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ELECTRONIC ARTICLE |
* Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Objective. Direct assessment of pediatric clinicians’ performance in identifying and managing obesity in clinical practice has not been conducted to date. The objective of this study was to determine rates of identification of obesity by pediatric residents, nurse practitioners, and faculty members in an academic primary care setting and to describe the actions taken by these providers in their evaluation and management of obesity.
Design. A retrospective medical record review of all health supervision visits for children 3 months to 16 years of age, examined between December 1, 2001, and February 28, 2002, was performed. For children <5 years of age, a weight >120% of the 50th percentile of weight-for-height was defined as obese. For children 
5 years of age, a body mass index of >95th percentile for age and gender was defined as obese.
Setting. A large, primary care practice located in a tertiary-care, academic, pediatric hospital, which serves a predominantly urban, minority (70% African American), Medical Assistance-insured (90%) population.
Participants. Primary care providers, including pediatric residents, nurse practitioners, and faculty physicians.
Results. Of the 2515 visits reviewed, a total of 244 patients met the study definition of obesity, yielding an estimated prevalence of obesity visits of 9.7% among health supervision visits for children 3 months to 16 years of age. This prevalence of obesity visits cannot be used to estimate the population prevalence of obesity, given the skewed distribution of visits toward very young children. For all children who met the study definition of obesity, providers documented obesity in their assessments in only 53% of the reviewed visits (129 visits). Although the majority of charts (69%) contained an adequate dietary history, only 15% included a description of the child’s activity level or television viewing. Obesity was noted in the physical examination in 39% of cases.
For children for whom obesity was identified as a problem by their clinicians (129 patients), 81% of charts contained an adequate dietary history, whereas 27% contained a description of the child’s activity level or television viewing. Obesity was noted in the physical examination in 64% of cases. Most children identified as obese by their providers received some management specific to their obesity, including education, screening, and specialist referral. Dietary changes were recommended for 71%, increased activity for 33%, and limitation of television viewing for only 5%. Eighty-three percent of providers recommended close follow-up monitoring. Other recommendations included referral to a dietitian (22%), screening laboratory studies (13%), a food diary (9%), endocrine referral (5%), or preventive cardiology referral (3%).
Provider identification of obesity was affected by the age of the patient and by the degree of obesity. Obesity identification was lowest among preschool children (31%) and highest among adolescent patients (76%). Providers evaluating older and heavier children were also more likely to obtain activity histories, note obesity in the physical examination, recommend changes in activity, refer the patient to a nutritionist, obtain screening laboratory studies, and recommend close follow-up monitoring. Identification of obesity and other outcome variables were not significantly influenced by the level of provider training or patient gender.
Conclusions. Although the prevalence of childhood obesity has now reached epidemic proportions, it was under-recognized and under-treated by pediatric primary care providers in our study. Providers identified obesity as a problem for only one-half of the obese children examined for health supervision. The lowest rates of obesity identification occurred among children <5 years of age and those with milder degrees of obesity. Identification did not improve with additional years of pediatric training.
Even for the subset of children identified as obese by their providers, evaluation and treatment often were not consistent with current recommendations. For example, more attention was given to the role of diet, compared with activity, in the evaluation of obesity. In particular, only a small number of providers (5%) recommended a decrease in television viewing to their obese patients, despite evidence linking television viewing and pediatric obesity. This finding is of concern, because obesity is known to be a multifactorial disease that responds only to significant changes in both dietary and activity behaviors. Only 13% of providers requested laboratory studies as part of their recommendations. The American Academy of Pediatrics currently recommends obtaining a lipid profile, total cholesterol level, and screening test for type 2 diabetes mellitus as part of the evaluation of obesity. The majority of clinicians who requested laboratory studies included thyroid function tests, which are not recommended by the American Academy of Pediatrics because of the very low likelihood of hypothyroidism as a cause of obesity. Although the extent of evaluation and management for children who were recognized as obese did not meet current guidelines, it was far better than that for patients who were not identified as obese by their providers. This demonstrates the importance of timely identification as the crucial initial step in the management of obesity. The results of this study are disheartening, especially as evidence mounts regarding the importance of early intervention in preventing the medical and psychosocial sequelae of obesity, as well as the persistence of obesity into adulthood. This study highlights the need for increased awareness and identification of obesity in the primary care setting, especially among younger children and those with mild obesity.
Key Words: obesity • primary care • identification
Abbreviations: BMI, body mass index
One of the most important developments in pediatrics in the past 2 decades has been the emergence of a new chronic disease, obesity in childhood and adolescence. As expressed by Sokol1 in an editorial "call to arms," the Western lifestyle has led to the super-sizing of our diet and the down-sizing of our activity, with the result that obesity is now the most common chronic illness in childhood.
The rapidly increasing prevalence of obesity among children is one of the most challenging dilemmas currently facing pediatricians. Comparison of National Health and Nutrition Examination Survey data from cycle II (1976–1980) versus cycle III (1988–1994) documented an increase in the prevalence of obesity in all age, ethnic, and gender groups.2 National Health and Nutrition Examination Survey data collected from 1999 to 2000 revealed a continued increase in the number of obese children.3 In that recent data collection, the prevalence of obesity (body mass index [BMI] of 95th percentile) was 10% among children 2 to 5 years of age and 15% among children 6 to 19 years of age. When children at risk for obesity (BMI of 85th to 94th percentile) were included, the values increased to 20% and 30%, respectively. Therefore, >1 of every 4 patients examined by pediatricians either is obese or is considered to be at high risk for developing this challenging health problem.
The prevalence of obesity varies significantly among ethnic groups, and African American youths are known to be at higher risk of becoming obese than are non-Hispanic white children.2,3 In a 10-year study investigating the development of obesity in a cohort of 2379 girls during adolescence, Kimm et al4 showed that, even at age 9 years, the prevalence of obesity was twice as high among black girls (18%), compared with white girls (8%).
The medical community is struggling to develop effective strategies for treatment of this epidemic, but timely identification of obesity by pediatric health care providers is a crucial initial step in the management of obesity. Direct assessment of pediatric clinicians’ performance in identifying and managing obesity in clinical practice has not been conducted to date. The objective of this study, therefore, was to determine the rates of identification of obesity by pediatric residents, nurse practitioners, and faculty members in an academic primary care setting and to describe the actions taken by these providers in the evaluation and management of obesity.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Setting
This study was conducted in a large, primary care practice located in a tertiary-care, academic, pediatric hospital, which serves a predominantly urban, minority (70% African American), Medical Assistance-insured (90%) population.
Participants
Participants included the pediatric residents, nurse practitioners, and faculty physicians who provided care in the primary care center.
Subject Identification
The BMI or weight-for-height percentile was calculated for the 2515 remaining children on the basis of the height and weight measured at the study visit. Primary care center nurses performed the height and weight measurements as was routine in their practice; they were not trained in a specific protocol for this study. For children <5 years of age, weight of >120% of the 50th percentile of weight-for-height was defined as obese. For children 5 years of age, BMI of >95th percentile for age and gender was defined as obese. Use of BMI of >95th percentile is consistent with the current expert committee recommendations, in which the panel recommends the use of the term "overweight" or "obese" for BMI of 95th percentile for age and gender.5 The expert committee, composed of pediatric obesity experts, was convened in 1997 by the Maternal and Child Health Bureau, Health Resources and Services Administration, and Department of Health and Human Services, to develop recommendations for the evaluation and treatment of childhood obesity.
Data Collection
For children who met the study definition of obesity, the provider’s progress notes were examined to determine the extent of the medical evaluation and the type of recommendations made for the management of obesity. The age, gender, height, and weight of the patient were recorded, as was the level of training of the provider. Each chart was then examined for the presence of the following: 1) an adequate dietary history (brief notations such as "varied" or "normal" were not considered adequate), 2) a history of physical activity and/or television viewing, 3) a notation of obesity in the physical examination, 4) a listing of obesity in the provider’s final assessment/problem list (identification), and 5) the presence and type of interventions outlined in the provider’s plan. Finally, we examined the follow-up monitoring recommended by the provider, with close follow-up monitoring being defined as a return visit that was earlier than the next health supervision appointment recommended by the American Academy of Pediatrics.
Data Analysis
For all visits in which the child met the study definition of obesity, including those in which the child was identified as obese by the provider, the frequency of the 5 outcome variables was determined. Bivariate analysis with 
2 tests was performed to determine whether independent variables (patient age, gender, and degree of obesity and clinician level of training) significantly influenced the identification of obesity and other outcome measures. To describe the degree of obesity, patients were divided into quartiles, with the least obese in the 1st quartile and the most obese in the 4th quartile. The measures of relative obesity used were the ratio of the child’s BMI to the age- and gender-appropriate 95th percentile BMI for patients 5 years of age and the ratio of the patient’s weight to the gender-appropriate 50th percentile weight-for-height value for children <5 years of age. Data were analyzed by using SPSS 11.0 for Windows (SPSS, Inc, Chicago, IL).
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Among the children who met the study definition of obesity, providers documented obesity in their assessments for only 53% of the reviewed visits (129 visits). Although the majority of charts (69%) contained an adequate dietary history, only 15% included a description of the child’s activity level or television viewing. Obesity was noted in the physical examination in 39% of cases (Table 1).
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Most children who were identified as obese by their providers received management specific to their obesity, including education, screening, and specialist referral. Dietary changes were recommended for 71%, increased activity for 33%, and limitation of television viewing for only 5%. Eighty-three percent of providers recommended close follow-up monitoring. Other recommendations included referral to a dietitian (22%), screening laboratory studies (such as cholesterol, lipid profile, fasting glucose, or thyroid function tests) (13%), maintenance of a food diary (9%), endocrine referral (5%), and preventive cardiology referral (3%).
Provider identification of obesity was affected by the age of the patient (Table 2) and by the degree of obesity (Table 3). Obesity identification rates were lowest among preschool children (31%) and highest among adolescent patients (76%). Although the analysis suggested that there might be an interaction between age and severity of obesity (Fig 1), a logistic regression model including both age group and obesity quartile as predictors of identification did not detect a statistically significant interaction between these 2 variables. This might be attributable to the relatively small numbers of adolescent children in each obesity category.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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As expected, obesity was found to be a common disease in our clinic visits, with a prevalence of obesity visits of 9.7%. This prevalence of obesity visits cannot be used to estimate the population prevalence of obesity, because of the skewed distribution of visits toward very young children. Because our practice follows the American Academy of Pediatrics recommended schedule for health supervision visits, approximately one-half of our well-child care visits are for children 
24 months, who are less likely to be obese.
In our study population at an academic center, primary care providers (including resident physicians, nurse practitioners, and attending physicians) identified obesity as a problem for only one-half of the obese children examined in the clinic. These results are consistent with those of the needs assessment questionnaire study described above, in which 50 to 61% of responders reported the initiation of treatment for overweight children with no obesity-associated conditions.7 Rates of obesity identification in our study did not vary according to the type of provider.
The lowest rates of obesity identification occurred among children <5 years of age. Obesity in this preschool age group deserves our attention. Obese 3- to 5-year-old children have a significantly greater risk of adult obesity, compared with their peers.8 Intervention in this age group is also more likely to be successful. Young children require smaller shifts in calorie balance to yield substantial changes in dietary intake, and habits are more easily changed when a few weeks or months represent a larger proportion of their total experience.9
Even for the subset of children identified as obese by their heath care providers, evaluation and management often were not consistent with current recommendations. For example, more attention was given to the role of diet, rather than activity, in the evaluation of obesity. The great difference in clinician attention to dietary versus activity factors is of concern, because obesity is known to be a multifactorial disease that responds only to significant changes in both dietary and activity behaviors.10 Helping families create opportunities for activity at home has become critically important, in an era in which <50% of children receive daily physical education at school.2
Only a small number of providers (5%) recommended a decrease in television viewing to their obese patients, despite evidence linking television and pediatric obesity.11–15 The average child watches 3 hours of television each day; this does not include time spent watching videotapes or playing video or computer games.16 One study of low-income preschool children showed that the amount of time spent viewing television and videotapes was significantly related to the prevalence of obesity within the population.17 Pediatricians may also be unaware of the growing popularity of placing television sets in children’s bedrooms and thus do not counsel against this practice. A television in the bedroom is even more strongly related to the risk of obesity than is the number of viewing hours.17 One-third of 2- to 7-year-old children and 65% of 8- to 18-year-old youths have television sets in their bedrooms.16
Only 13% of providers requested laboratory studies as part of their recommendations. The expert committee recommends obtaining a lipid profile, a total cholesterol level, and a screening test for type 2 diabetes mellitus as part of the evaluation of obesity.5 Also, the majority of clinicians who requested laboratory studies included thyroid function tests, which are not recommended by the expert committee because of the very low likelihood of hypothyroidism as a cause of obesity.
It is worth noting that, although the extent of evaluation and management among children who were recognized as obese did not meet current guidelines, it was far better than that among children who were not identified as obese by their providers. This demonstrates the importance of timely identification as the crucial initial step in the management of obesity.
One limitation of this study was the reliance on the documentation of health care providers, which might not reflect completely the provider’s observations of the patient or the discussion with the patient and family that took place during the health supervision visits. Future research is needed to determine whether documentation of obesity is an accurate indication of provider recognition and actions.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The results of this study are disheartening, especially as evidence mounts regarding the importance of early intervention in preventing the medical and psychosocial sequelae of obesity, as well as the persistence of obesity into adulthood. This study highlights the need for increased awareness and identification of obesity in the primary care setting, especially among younger children and those with mild obesity.
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ACKNOWLEDGMENTS |
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We thank Drs Ellen Wald and Alejandro Hoberman for their support and thoughtful critique of the manuscript.
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FOOTNOTES |
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Reprint requests to (E.C.R.) General Academic Pediatrics, Children’s Hospital of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA 15213-2583. E-mail: evelyn.reis{at}chp.edu
S.H.O. received the 2002 Region III Ambulatory Pediatric Association Research Award for her abstract of this report.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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